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� City of Orono
<br /> Building Permit Application for Maintenance/ Replacement J Remodel— Residential ONLY
<br /> {i,e. windaws, doors, siding, re-raof, etc. - NO STRUCTURA� EXPANSION)
<br /> � � Mailing Address: ����7 �C�
<br /> � � PO Box 66 Permit number: ��
<br /> Crystal Bay,MN 55323-0066 Date received: ::�
<br /> �, � Street Address: Received by:
<br /> y�, G� 2750 Kelley Parkway Plan revisw fee:
<br /> ��KFs Ho'�`` Orono,MN 55356 —
<br /> Total Fee: � ��,�
<br /> Main: 952-249�i600 Fax: 952-249-4616 www.ci.orona.mn.us
<br /> This application form must be completed in full and all required infonnation must be submitted.
<br /> Incomplete appllcations will be returned. (Please print)
<br /> GENERAL INFORMATION:
<br /> Job Site Address: .,� Z ,-
<br /> WIII this be a Parade of Homes, Remodelers Showcaae Home or other Dfaplay Home? Yes No
<br /> N yss,a specia/event permit is required with Po/ice DepaRment and City Counci/approvaJ 60 days pnor to the event. Shutt/e bus servi wil/be
<br /> required unless app/icant demonstrates sufficient on-sRe parking is availabJe. Non-permitted evenls will not be allowed.
<br /> CONTRACTOR/APPLICANT INFORMATION:
<br /> Name: ��7 ��-,,,�n ,�,,�.�s 6� �, � S /-��i)LrLiL"t-r� �.��
<br /> State License# Expiraiion Date:
<br /> Lead Certification Number: Expiration Date:
<br /> (fnr work on homes that were constructed priar M 1978
<br /> Phone: {cell) � ��- a- /.�- � /� � (office) C�. �'�- C/7�.`'�� O
<br /> Mailing Address: City: ZIP:
<br /> Contact Pe�son: �> �C.��2� �1� s�c n��n� Applicant is: Contractor Homeown �circwa,.�
<br /> Email and/or Fax: � ,�M�j ���`e�,A�. �;:�
<br /> PROPERTY OWNER INFORMATION:
<br /> Name: _t,�2�i s;, �,�,n au n ���,..1 r-n �. � LG.G
<br /> Phone(day): �� �� Z �� �-�_
<br /> Address: _ c,i ai �-�-L`f ..S 7'"" E t�' City: �l�(/�-f9-Ti'fi ZIP: .S S '�� /
<br /> Email and/or Fax: �/.},�/,� � �,n r),�',��L_ C'� .iY!
<br /> PROJECT INFORMATION: Overall ro ect descri tion:
<br /> ���;�� Type of Project: Any earth movement may alaa require
<br /> MCWD review& rn�its:
<br /> ��� ��,Door(s) � Remodel ❑ Firs Damage �
<br /> � Re-roof,asphalt ❑ Repair ❑ Storm Damag� Minnehaha Cr+eek Watershed District(MCWD)
<br /> ❑ Re-roof,cedar 15320 Minnetonka Blvd
<br /> ❑ Restoretion gj Water Damage Minnetonka, MN 55345
<br /> ❑ Re-roof,other�specify) ❑Siding ❑Other:(speciy) Phone: 952-471-0590
<br /> Fax: 952-471-0682
<br /> ,�,/.�H/ Ra-ral k^v� ❑Window(s) �i N'�Ii� -��1c���N www.minnehahacreek.orp
<br /> Estimated Construction Valuatton of Project(excluding land) S __,�_;,�4
<br /> APPLICANT ACKNOWLEDGEMENT:
<br /> • Agrees to provide all information required or requested by the Building Depart�nt;
<br /> • Certifies that the information supplied is true and coRect to tfie best of his/her knowledge. The applicant recognizes that they are
<br /> solely responsible for submitting a complete application being aware tfiat upon failure to do so,the staff has no altemative but to
<br /> reject it until it is complete;
<br /> • Some or all of the information that you are asked to provide on this application is Gassified by State law as either private or
<br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the data.
<br /> Confidential data is information wtiich generaNy cannot be given to either the public or the subject of the data. Our purpose and
<br /> intended use of this information is to annually update our records and records of other governmental agencies required by law. If
<br /> ou refuse to su I the inforrnation the a lication ma not be issued.
<br /> ApplicanYs Signature: Date:
<br /> Owner's Signature:��„ � �.-� c�.r�'n�����,Date:t1/�,c� c.�_� -�.oi 7
<br /> � T; .
<br /> Last Updated:January 2016 f
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